The aims and effectiveness of communities of practice in healthcare: A systematic review

Communities of practice (CoPs) are defined as "groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis". They are an effective form of knowledge management that have been successfully used in the business sector and increasingly so in healthcare. In May 2023 the electronic databases MEDLINE and EMBASE were systematically searched for primary research studies on CoPs published between 1st January 1950 and 31st December 2022. PRISMA guidelines were followed. The following search terms were used: community/communities of practice AND (healthcare OR medicine OR patient/s). The database search picked up 2009 studies for screening. Of these, 50 papers met the inclusion criteria. The most common aim of CoPs was to directly improve a clinical outcome, with 19 studies aiming to achieve this. In terms of outcomes, qualitative outcomes were the most common measure used in 21 studies. Only 11 of the studies with a quantitative element had the appropriate statistical methodology to report significance. Of the 9 studies that showed a statistically significant effect, 5 showed improvements in hospital-based provision of services such as discharge planning or rehabilitation services. 2 of the studies showed improvements in primary-care, such as management of hepatitis C, and 2 studies showed improvements in direct clinical outcomes, such as central line infections. CoPs in healthcare are aimed at improving clinical outcomes and have been shown to be effective. There is still progress to be made and a need for further studies with more rigorous methodologies, such as RCTs, to provide further support of the causality of CoPs on outcomes.


Introduction
Medical knowledge is estimated to double every 73 days [1], leaving both physicians and patients with a seemingly insurmountable amount of information to stay on top of.This essentially means those involved in healthcare have to become skilled at knowledge management, defined as 'the collection of methods related to creating, sharing, using, and managing the knowledge and information of an organisation' [2].
One knowledge management strategy that has received significant attention is the theory of communities of practice (CoPs).CoPs are defined as "groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis" [3].CoPs have a domain of interest, a community of individuals who all share that interest, and a practice consisting of the shared knowledge and skills built up by the community.
Initially described in the business sector, they have been particularly effective as a mechanism for the sharing of tacit knowledge [4].First described by Polanyi, the Hungarian-British philosopher in 1966 [5], tacit knowledge, in comparison to explicit knowledge, is very difficult to directly codify and share in guidelines.It is best communicated through direct observation and imitation as well as through conversations, stories, and metaphors.The medical profession is a clear example of one where tacit knowledge is constantly used, exemplified by the 'mindlines' (rather than guidelines) that practitioners tend to follow [6].
There has been an evolution of the concept, when initially described by Wenger and Lave, they were highly location specific, to a certain office or workspace, where individuals working together would interact, bouncing ideas off each other and helping newer members become fully integrated into the working environment.Over time, the description altered to include those who were not working together in the same physical place, but still shared the same domain of interest and were working on the same set of problems.This opened up the opportunity for virtual CoPs (vCoPs) to be included in the definition, where communities from all over the world interact digitally, producing the same tacit sharing effects as those working in the same physical space.
This review looks to elucidate the aims and effectiveness of CoPs in healthcare as well as communication methods used in these CoPs.We will also show what barriers and facilitators CoPs find when they are implemented in healthcare settings.

Material and methods
In May 2023 the electronic databases MEDLINE and EMBASE were systematically searched for primary research studies on CoPs published between 1st January 1950 and 31 st December 2022.PRISMA guidelines were followed.
The following search terms were used: community/communities of practice AND (healthcare OR medicine OR patient/s).The search was limited to research on human subjects and papers published in the English language.There was no restriction on geographical location.
This review was limited to original research with a focus on CoPs in the healthcare sector.Only papers published in peer-reviewed journals were included.Exclusion criteria were as follows: • Studies reporting on CoPs in sectors other than healthcare.
• Studies reporting on medical education.

• Studies reporting on multiple interventions
• Case studies.
• Records with no abstracts.

• Study protocols • Review articles
• News-style or opinion articles, theses and dissertations, and abstracts of conference proceedings without full peer-reviewed papers.
The search was completed using Ovid, and the reference list was uploaded to Covidence.Two authors (APN and HSP) independently reviewed all titles and abstracts, checking against inclusion and exclusion criteria.Relevant papers were marked for retrieval of full text and detailed review.When decisions differed, a final decision was made after discussion between the two reviewers.One author (APN) reviewed and extracted using a standardised template.Reference lists of included studies were also screened.When relevance of the paper was uncertain, or the findings were difficult to extract, APN discussed the paper with UJ.PRISMA flow diagram can be seen in Fig 1.The following data were extracted: study details (author name, year of publication, country, sample size, study design, study type, data collection method, data analysis method, outcomes measured, barriers/facilitators, and limitations) and description of the CoP (including population, why it was established, how it was established, method of communication, and content shared).
Bias was assessed using the Critical Appraisal Skills Programme (CASP) checklist.Microsoft Excel was used to build tables of the studies included in this review.This review was not registered and a protocol was not prepared.Template data collection forms and data extracted from included studies is available upon request.

Results
The database search picked up 2009 studies for screening, of which 94 studies were eligible for full-text review.Of these 50 papers met the inclusion criteria for this systematic review.The most frequent reason for exclusion at this stage was that the study included multiple interventions of which only one was a CoP.Total participants in CoPs across the studies were 12,400, with an average of 282 participants per study (6 studies did not report participant number).

The aims of the CoPs
There were a number of themes that emerged from the aims of the CoPs examined in this study (Table 1).The most common by far was to directly improve a clinical outcome, with 19 studies aiming to achieve this.This included disease related factors such as reducing central line infections [9], improving glucose control in critically ill patients [40], and increasing viral suppression rates in HIV [51].This theme also included many aspects of improving clinical services and workflows such as improving rehabilitation for patients with AF [49], improve pain practices for spinal cord injury patients [43], and improve the falls prevention care for care-home residents [34].
Developing skills was also a common reason for setting up a CoP with 8 studies in this theme.This included building research skills [29,32] and developing self-care techniques [48].There were also 7 studies whose aim was to share best-practice.This included the direct sharing of evidence-based practice [12,50] as well as trying to decrease variation in practice over geographically spread out areas by providing clinicians in the same speciality a means of communication [11,41,44].
Sharing specialist knowledge was the aim of 6 studies.Of these, 4 were aimed at connecting primary care physicians with hospital-based specialists [14,27,39,45] for example providing rural primary care physicians the knowledge to manage patients with chronic hepatitis C infection [14].Another 3 studies brought clinicians together with researchers with the aim to stimulate research ideas and activity [8,36,46].Other notable CoPs were set up with the specific aim to complete a specific task, such as develop a set of standards for genetic counselling in Europe [15], or to co-design a smartphone application with patients for schizophrenia care [33].

Effectiveness of the CoPs
The effectiveness of the CoPs was measured in a variety of ways (Table 1).30 studies were qualitative research, 20 studies used a non-randomised experimental design, and 1 study was a randomised controlled trial [25].In terms of outcomes, qualitative outcomes were the most common measure used in 21 studies, a mix of both qualitative and quantitative outcomes were used in 20 studies, and solely quantitative outcomes were used in 9 studies.Only 11 of the studies with a quantitative element had the appropriate statistical methodology to report significance.All except 1 study [40] reported a positive significant effect when implementing a CoP.Outcomes varied across geographical location with North American countries such as Canada (91.7%) and USA (80%) having a higher percentage of studies with a quantitative element to their outcomes, in comparison to the UK (12.5%) or Australia (50%).
Of the 9 studies that showed a statistically significant effect, 5 showed improvements in hospital-based provision of services [12,25,35,47,49,55].These studies included implementing patient orientated discharge summaries leading to an 7% increase (p = 0.026) of family involvement during discharge [47], as well as another study improving rehabilitation services for patients with atrial fibrillation (AF) which demonstrated an increase in patients' knowledge about AF (p = 0.02) [49]. 2 of the studies showed improvements in primary-care.Arora et al. showed how bringing primary care providers together with hospital specialists improved primary care knowledge about the management of hepatitis C infection (p<0.0001).Diaz-Chao et al. showed how bringing primary care physicians together with specialists led to fewer hospital referrals (p<0.05).Finally, 2 studies showed improvements in direct clinical outcomes.One study showed a reduction in central line infections by 50% (p<0.05)(9) and another showed an increase in HIV viral suppression rates from 79.2% to 82.3% (p<0.05)[51].

Communication
Table 2 describes the methods of communication utilised by each of the communities of practice described in the 50 studies included in this review.Of the communities of practice 23 communicated virtually, 12 communicated face-to-face, and 13 used both face to face and virtual methods of communication.In two of the studies [26,41], it is unclear whether the communication was virtual, face-to-face or both.23 of the communities of practice held meetings for the members, 10 utilised workshops, 8 described seminars, and 1 described tutorials [42].25 studies communicated using web-based systems and blogs and 10 communicated via email.18 of the studies described other methods of communication, which included video consultation [49], telephone-based catch-ups [14,18] and case based presentations/discussions [14,19,23,51].The average year for face-to-face only communication was 2014.25 (SD 4.94) and 2015.78(SD 5.56) for virtual only communication, which was not significantly different (p = 0.43).

Barriers and facilitators
Barriers to engagement were reported in 15 of the studies; examples are given in Table 3.The biggest barrier to engagement was time constraints, reported in nine of the studies.Lack of space to meet up [18], or to access the vCOP [42] was reported in two of the studies, and lack of funding [43] or resource constraints [12] as a barrier was reported in two studies.Difficulty accessing the COP platform via usual workstations [39] or operating systems [42] was listed as a barrier in two of the studies.A lack of understanding of the concept of the COP was reported as a barrier in one study [10]; two studies cited fear of judgement as barriers to engagement [11,53].One study noted that those who were encouraged to join the COP by peers had lower engagement than those who self-selected [29], whilst another found that lack of participation by peripheral members caused frustration among core members [21].Facilitators were reported in 24 of the studies; examples are given in Table 4.The most commonly highlighted facilitators were involvement of key members of the team.Primarily these were clinical, with studies citing strong clinical leadership [26,39], support from health [16] or hospital [9] leadership, clinical champions [11,24], experts [34,38], and involving PCPs in the early stages of development [45].Non-clinical roles were also highlighted, with two of the studies listed having a group facilitator important for engagement [21,42], and one highlighting the importance of funding for an administrative coordinator [36].One study found that a mentoring scheme helped to distribute expertise [36], whilst another found the opportunity for new members to learn through passive participation to be a facilitator [8].Regular face to face meetings were listed by three of the studies as facilitators [36,38,49], with one study noting that using face-to-face and virtual activities supported different learning styles [35].Use of social networks and ICT technologies in professional practice were found to be facilitators in one of the studies [36].Alignment with existing practices, in particular with quality improvement methodology, was noted to be a facilitator in two of the studies [24,29].

Discussion
This systematic review has elucidated the aims and effectiveness of CoPs established in a healthcare setting.As described above, there were a variety of aims for the CoPs, with the majority relating to improving clinical outcomes and knowledge.Although encouraging to see the focus of these CoPs on clinically relevant issues, there were only 3 studies [9,40,51] where

Time constraints
The time commitment was the biggest barrier [41] Space constraints Barriers included. . .a lack of space to meet up [18] Resource constraints A lack of funding resulted in longer implementation times [43] Information Technology constraints Not having the tool integrated into usual work stations. . .proved to be a barrier [39] Lack of understanding Barriers included not understanding the CoP concept [10] Fear of judgement Barriers. . .included. . .concern about how interesting a case is, and showing a gap in one's knowledge [11] Mode of selection Those who were encouraged to join the CoP by peers, rather than selfselecting, had lower engagement [29] https://doi.org/10.1371/journal.pone.0292343.t003 the outcome measurement was a patient related clinical outcome with the suitable statistical methodology to determine a significant effect.Furthermore, only 1 study [25] had a randomised control trial (RCT) design and therefore the ability to establish causality.In this study, 122 veterans affairs (VA) hospitals were randomised to have enrolment into a new initiative facilitated either by a CoP or through usual means-the standard national announcements that all hospitals receive for new initiatives.The initiative was the national hospital to home (H2H) project, and uptake to the programme was the primary outcome measure.H2H aimed to help inpatients with heart disease transition back to their place of residence through measures such as early follow up and patient education to recognise early signs of deterioration.The CoP was an already existing entity that had been set up previously to connect VA hospitals to improve the quality of care for patients with heart disease.The primary means of communication of the CoP was via email and they also had bimonthly teleconferences.54% of the hospitals randomised to CoP facilitated arm enrolled in the H2H initiative whereas only 10% of those not facilitated by the CoP enrolled (p < 0.001).This is clear evidence of the effectiveness of utilising CoPs, albeit indirectly, for changing clinical practice.However, the ultimate goal of the H2H was to reduce 30-day readmission rates by 20%, and this study did not measure and compare this, which would have provided a more clinically meaningful endpoint.
Although not formally described as CoPs, and therefore were not picked up in the systematic search of this review, there are other RCTs published in the literature that provide support for the effectiveness of CoPs directly on clinical outcomes.Described as peer-mentoring schemes or online communities, lifestyle interventions that bring patients together who share the same set of problems, such as poor glucose control or low activity levels, have been highly effective at motivating patients to alter their behaviour [57,58].Richardson et al. conducted an RCT that provided the intervention arm with means of communication with their fellow patients during an online intervention to increase physical activity.Those able to communicate with their fellow participants, through posting and reading messages on a web-based blog, had a significantly reduced attrition rate than those who had no means of communication (79% v 56%, p = 0.02).
As the most common outcome of the CoPs was a change in practice, it is clear that as well as being a knowledge management strategy, CoPs are also behaviour change interventions.The capability, opportunity, and motivation model of behaviour change (COM-B) is a systematic way of framing the different facets required for an individual to change their behaviour [59].Capability is defined as the psychological and physical requirements to perform the task.Opportunity represents the physical and social factors outside of the individual that make the behaviour possible, and motivation is defined as both the reflective and automatic brain

Clinical leadership
Strong clinical leadership was the most important success factor [26] Hospital/health leadership support Support of the CoP by health leaders was a major facilitator [16] Expert knowledge Facilitators included access to a panel of experts [34] Group facilitators The facilitator motivated members to contribute and filtered in relevant information [42] Clinical champions Facilitators included the existence of a champion in the field [11] Administrative coordinator The funding for the administrative co-ordinator has been a facilitator [36] Quality improvement methodology Methodology that closely resembled quality improvement and allowed for quick wins kept the groups engaged [29] https://doi.org/10.1371/journal.pone.0292343.t004 activity that energises and directs behaviour.Through the community and shared problem solving that CoPs offer, it is clear that they provide individuals with the psychological capability, social opportunity, and motivation they need for behaviour change through the learning resources and peer support available.The main barrier to engagement was time constraints, which are to be expected in an overwhelmed healthcare environment that is busier than ever [60].Funding constraints were also noted, which once again is not a surprise as healthcare spending as a percentage of GDP is at its lowest in a decade [61].It is, however, encouraging to see that there were no barriers relating to a lack of digital skills, despite many individuals known to struggle [62].With the digital revolution taking place in healthcare, strong digital skills in the workforce will be necessary to control spiralling costs.Such skills will be necessary for vCoPs to be taken up in a meaningful way across the healthcare ecosystem.
The main facilitator for engagement was strong leadership, including support from institutional leaders, which represents an alteration from the original vision for CoPs as self-organising entities with a lack of centralised leadership.This shows the specific healthcare related factors that many interventions face in the highly regulated and controlled environment.Future CoP endeavours should bear this in mind and make sure support and buy in is gained from the relevant clinical and administrative leaders.This will also help alleviate the main barrier to engagement by providing support or even specific protected time for the CoP.
CoPs differ from other knowledge management strategies such as work groups or knowledge networks.In work groups goals are pre-determined by a manager and members are usually assigned or selected by a leader.CoPs on the other hand goals are negotiated by members and membership is self-selecting, by identifying with the domain of knowledge of the CoP.Knowledge networks are at the other end of the spectrum to work groups and are an informal set of relationships which are primarily concerned with passing on knowledge, rather than the full range of knowledge management.In comparison, CoPs have a shared mission and desire in its members to work together to deepen their knowledge.CoPs also focus on the creation, storage, and utilisation of knowledge.
This review had a number of limitations.Only studies that directly had mention of a community of practice in the title, abstract, or full text were included.This meant that the diverse array of names used to refer to the concept of CoPs, such as situated learning, learning network, or even just community, were not included potentially excluding valuable studies.However, these phrases are used too ubiquitously in the field of healthcare, and as such, so broad a search was not feasible and so the search was focussed solely on the term community/ies of practice.Studies regarding medical education were also excluded, as has similarly been done in previous reviews [63], as these participants wouldn't necessarily be involved in providing healthcare directly.However, these studies may still have provided insights into the barriers and facilitators of engagement with healthcare themed CoPs.This review also did not employ a snowballing technique to examine the full list of references in each included study to broaden the search methodology.It was also not technically possible to carry out a logistic regression looking for the factors that were associated with effective CoPs as only 1 study reported a negative result.
CoPs in healthcare are aimed at improving clinical outcomes and have been shown to be effective.There is still progress to be made and a need for further studies with more rigorous methodologies, such as RCTs, to provide further support of the causality of CoPs on outcomes.As healthcare systems continue through their digital transformation journeys and healthcare workers have to manage an ever-mounting amount of knowledge, vCoPs in particular offer a method for improving outcomes and sharing vital information across an ever more complex healthcare landscape.